Issue-19 | Quarter-3, 2017

reflection Quarterly Newsletter

Celebrating 40th Foundation Day of United Group

United Group, one of the largest
business conglomerates of the country,
celebrated its 40th Foundation Day on
12 July 2017. The group is committed to
socio-economic development of the
country by continuously enhancing
value of its stakeholders and striving to
be a socially responsible corporate
entity by supporting community engage-
ment activities.
In his inspiring speech, the Group
Chairman Mr Hasan Mahmood Raja
shared the aspiration that United Group
nurtures to take the company forward in
the coming days and he urged every
employee to uphold this goal in a
homogenous way from every corner;
each employee working as an
ambassador of United Group. He
emphasized on maintaining a conducive
working atmosphere with family bonding
between everyone; he further stressed
upon the need to be dedicated in
demonstrating social responsibility in the
pursuit of nation building endeavors.
On this occasion, the Board of Directors
conveyed in their message the immense
value that they give to their human
resource & stakeholders being the
driving force of the company; they
expressed their pledge to create higher
opportunities for enhancing their
contribution and growth in the days to
come.

Editor’s Note Commemoration of 11th Anniversary of United Hospital

In the 3rd quarter of the year, On 24 August 2017, United Hospital touched who reminded all to be cautious in delivering
we had moments of pride the milestone of completing 11 years of responsible services to the patients as United
being pioneer in coun- healthcare service. The day was observed Hospital with its growing age, needs to meet
try-first life-saving proce- solemnly with raising of the hospital flag at growing expectations of the society. CEO,
dures like TAVI, we also had dawn followed by Quran Khani and special departmental chiefs, Consultants, nurses and
busy interactive learning prayers for the recovery and good health of all others of the hospital were also present in the
participatory in-house & the patients in general and for those of the booth where a good number of patients and
outreach engagement hospital. A day long complimentary basic health their attendants availed complimentary health
sessions from all level of checkup booth was organised at hospital lobby checkup, doctor consultation and diet
hospital staff to Consultants which was inaugurated by Mr Faridur Rahman counseling. Special menu lunch was arranged
in different local & interna- Khan, Managing Director of United Hospital, for all hospital staff on the day.
tional programs. The
articles in this quarter
display varied cases truly
depicting the multi specialty
clinical treatment atmo-
sphere of United Hospital.
Our deepest sympathy
goes to the flood affected
community of the country
and we further appreciate
the individual & collective
effort of hospital staff for
helping them.

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 Issue-19 | Quarter-3, 2017

Acute Anteroseptal ST Segment Elevation Myocardial Infarction: A

Misnomer
Professor H I Lutfur Rahman Khan, Professor Abdul Wadud Chowdhury, Dr N A M Momenuzzaman, Dr Kaiser Nasrullah
Khan, Dr Fatema Begum, Dr Tunaggina Afrin Khan

“The term anteroseptal STEMI neither implies that the No differences were observed between the two groups in
ischemic process is limited to the anteroseptal segments, nor baseline characteristics; except AS-STEMI group had more
that the size of the ischemic area at risk is smaller than that patients with diabetes and EA-STEMI group had more
in patients with extensive anterior STEMI.” patients with family history of coronary artery disease.
Post myocardial infarction (MI) short and long term clinical Comparison of mean of total involved segments and
outcome is largely determined by the size of the infarcted ejection fraction between two groups (n=196)
area. It is generally assumed that as the lead involvement in
electrocardiography (ECG) is less in anteroseptal ST Total Groups
segment elevation myocardial infarction (AS-STEMI), where involved Group I Group II P (95% CI)
ST segment elevation (STE) is limited to leads V1 to V3, segments (n=90) (n=106)
myocardial damage is likely to be less; and in extensive ante-
rior STEMI (EA-STEMI), as the STE extends further upto V6, Mean 8.83±2.49 9.01±2.25 0.604NS
the myocardial damage is likely to be more. This study was ±SD (.492 to .498)
intended to compare regional wall motion abnormality Groups
(RWMA) between acute anteroseptal STEMI and acute Ejection
Group I Group II P (95% CI)
extensive anterior STEMI patients. fraction
(n=90) (n=106)
This cross sectional analytical study was carried out in
Dhaka Medical College Hospital; 90 patients with AS-STEMI Mean ± 38.8±5.78 39.21±5.90 0.627NS
and 106 patients with EA-STEMI, admitted in between Octo- SD 2.059 to 1.245)
ber 2012 and September 2013, were included. For each
patient, a transthoracic echocardiogram (TTE) was Group I (AS-STEMI), Group II (EA-STEMI), P value derived
performed within 24-48 hours of MI and was interpreted by from Student t test. NS = not significant,
an independent investigator blinded to the patient's ECG
data. The left ventricle was divided into 17 segments (6 In conclusion the term AS-STEMI may be a misnomer, as it
basal, 6 mid-ventricular, 5 apical).13 Comparison of RWMA implies that only the anteroseptal segments of the left
between the two groups for each of the 17 segments was ventricle are involved. This study shows that regional
done. Global wall motion abnormality was compared dysfunction in patients with AS-STEMI extends beyond the
between the groups on the basis of ejection fraction (EF%). anteroseptal region.

1. Basal Anterior 7. Mid Anterior 13. Apical Anterior LAD

2. Basal Anteroseptal 8. Mid Anteroseptal 14. Apical Septal RCA
3. Basal Inferoseptal 9. Mid Inferoseptal 15. Apical Inferior LAD or RCA
4. Basal Inferior 10. Mid Inferior 16. Apical Lateral LCX or LAD
5. Basal Inferolateral 11. Mid Inferolateral 17. Apex LCX or RCA
6. Basal Anterolateral 12. Mid Anterolateral LAD or RCA or LCX

17 segment model of left ventricle with respective coronary circulation.

Scientific Seminars on PET CT

Like last quarter, United Hospital organized Scientific Seminars on PET CT in different
institutions of Dhaka to disseminate the updated status & role of PET CT to diagnose different
types of cancer and the role that United Hospital is playing. Dr M A Wahab, Consultant,
Nuclear Medicine Department of United Hospital delivered presentation in these sessions.
Date Institute Topics
National Institute of Diseases of the Molecular Imaging in Lung Cancer
23 July 2017
Chest & Hospital (NIDCH)
25 July 2017 Uttara Adhunik Medical College A Surprise for Cancer Imaging
12 August 2017 BIRDEM Wonderful Imaging Modality for Oncology
16 August 2017 Ahsania Mission Cancer & General Molecular Imaging in Lung Cancer
Hospital
23 August 2017 Dhaka Medical College Hospital Impact of PET CT in Management of
Colorectal Cancer

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United Hospital Cardiac Centre conducted country’s first ever Transcatheter
Aortic Valve Implant (TAVI), a minimally invasive non-surgical procedure
On 25 July 2017, first time in Bangla-
desh, the excellent team effort of Chief
Cardiologist Dr Momenuzzaman and
Chief Cardiac Surgeon Dr Jahangir
Kabir, led to a successful TAVI proce-
dure on Dr Sayeedur Rahman, a 85year
old renowned Dental Surgeon of
Barisal, who was suffering from age
related Aortic Stenosis; this was
declared in a press conference in the
hospital to newspaper and TV reporters.
As a person gets old, calcium deposit
increases in heart valve and heart valve
movement ability goes down. Since
Aortic Valve is a high-pressure valve
(under huge blood flow pressure), as its
performance gets diminished, patient
Secondary Spontaneous Pneumothorax: A Case Report
Dr Jahangir Talukder, Dr Safia Binte Rabbani
Pneumothorax is defined as collection
of air in pleural space. Tension
pneumothorax is a medical emergency
where modified water seal drainage
needs to be given on emergency basis
initially. Other treatment options are
percutaneous needle aspiration,
intercostal tube drainage (ICT) and
pleurodesis in case of recurrent
pneumothorax. After management of
pneumothorax, later actual cause of
pneumothorax should be treated such
as rupture of tuberculous cavity which is
common in our country and should be
treated with antitubercular therapy.
A male patient of 55 years was admitted
in United Hospital with history of
breathlessness and dry cough for 4
days. He was a smoker and a known
case of hypertension and chronic
obstructive pulmonary disease.
Besides, he gave history of pulmonary
tuberculosis and treatment with
antitubercular drugs 20 years back.
On admission, he was having
dyspnoea, his pulse was 120/min and
blood pressure was 190/120 mm Hg,
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Issue-19 | Quarter-3, 2017
starts having symp- (TAVI) is a risk-free life-saver procedure
toms of chest pain, done with simple sedation and local
fainting episodes and anaesthesia in 50-55 minutes. With
unbearable increasing Open Heart Surgery Aortic Valve
cough. It is a deadly Replacement patient needs to stay in
disease because hospital for atleast 7-10 days, whereas
these patients are in with TAVI done in Cath Lab, patient can
high mortality risk i.e. go home in 2-3 days and can resume
when they come to normal day to day activities in 4-5 days.
doctors with active symptoms, they With increase in life expectancy and
mostly survive for another 2-5 years increase in incidences of age-related
after that. The only remedy is aortic diseases, TAVI can save lives in Aortic
heart valve replacement, which can be Stenosis thereby can play an important
done by open heart surgery, but patients role in keeping country’s these intellec-
at old age with many other complica- tual senior citizens productive.
tions like kidney
insufficiency, lung
problem or block in
heart vessels,
might be at severe
risk of surgery and
anaesthesia.
Hence for such
patients, Trans-
cather Aortic Valve
Implantation
SpO2 was 80% in room air. Physical During discharge, patient was advised
examination of respiratory system not to air travel for next 6 months as
revealed hyper-resonant percussion recurrence may occur within 6 months
note and silent chest on auscultation of even after thoracic surgery.
right side. No abnormality was detected
in other systems. Chest X-ray showed
hyper-translucent right lung field with
sharply defined compressed lung
margin suggestive of right sided pneu-
mothorax. In view of above the patient
was diagnosed as a case of moderately
large secondary spontaneous pneumo-
thorax of right side. Since the patient
was symptomatic so immediate inter- Initial CT scan of chest showing: right sided
costal tube (ICT) insertion was done to pneumothorax
bring out the entrapped air from right
pleural space. Patient’s right lung was
fully expanded after ICT insertion.
Unfortunately because of patient’s
movement, ICT got displaced and
patient developed surgical emphysema.
Air bubble was found to be present even
at the end of 7th day of ICT drainage.
Patient was advised to undergo bron-
chopleural fistulectomy by thoracic After insertion of intercostal drainage tube
there was full expansion of right lung with
surgeon as this turned out to be a case small pneumothorax after 7 days, suggesting
of open pneumothorax. open pneumothorax
3 >>>

A Preliminary Evaluation of Respiratory Gated Volumetric Modulated
Arc Therapy in The True Beam Linear Accelerator – A Dosimetric Study
Karthick Raj Mani, Anisuzzaman Bhuiyan, Ramaa Lingaiah, Faruk Hossain, Anamul Haque
Volumetric Modulated Arc Therapy
(VMAT) replaced a standard form of
Intensity Modulated Radiotherapy
treatment (IMRT) in most of the health
care set-up due to it’s superior dose
distribution with reduced treatment time
and monitor unit. Intra fraction organ
motion during the treatment delivery is
one of the major concerns. In this study
we tried to evaluate the accuracy of dose
delivery with respiratory gated VMAT.
Five previously treated patients (2
Hepatocellular Carcinoma HCC and 3
Lung cancer) were included in this study
to evaluate accuracy of the gated VMAT
dose delivery. All the patients were
simulated with retrospective 4DCT.
Entire respiratory cycle was divided into
10 bins or CT datasets (ie.
0,10,20,30,40,50,60,70,80 & 90). The
MIP (Maximum Intensity Pixel), AIP
(Average Intensity Pixel) and MIN
(Minimum Intensity Pixel) were created
from the deep inspiration period (i.e. 90,
0 & 10). All the patients were planned to
Zika: A new threat to Newborn Health
Dr Nargis Ara Begum, Dr Sharmin Afroze
In the past two decades, many impor-
tant vector-borne diseases have
re-emerged and spread to newer parts
of the world. Zika virus is one of them,
which was first isolated in 1947 from a
monkey in the Zika forest, Uganda;
since then sporadic cases were
reported worldwide. In 2015, 84
countries and territories reported
evidence of vector-borne Zika virus
transmission. Other than mosquito
bite it can be transmitted from
mother to fetus during pregnancy or
around the time of birth. Affected
individuals suffer from fever, rash,
joint pain and red eyes. Usually
disease severity is mild and
resolves spontaneously within few
days to weeks. Intrauterine Zika virus
infection causes miscarriage and early
neonatal death, fetal microcephaly,
fetal malformations and neurological
disorders, cerebral calcification, ocular
abnormalities like loss of foveal reflex,
macular neuro-retinal atrophy
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deliver VMAT delivery with 6MV FFF
beam using gated and non-gated
technique. A dosimetric comparison was
made between the gated and non-gated
delivery using ion chamber matrix and
absolute dosimetry was also performed
to evaluate the delivery accuracy.
For regular sinusoidal motion, the dose
delivered to the target was not
(diagnosed in three children in January,
2016) and Guillain-Barré syndrome
(later in life). WHO declared the cluster
of microcephaly cases and other neuro-
logical disorders associated with Zika
infection a public health emergency of
international concern (PHEIC) on 1
Feb, 2016. Since then the Government
of Bangladesh has been addressing
the iceberg of the problem and has
already taken some initiatives for Zika
preparedness in our country. Preva-
lence of the vector Aedes Aegypti mos-
quito in Bangladesh, adds more to the
Issue-19 | Quarter-3, 2017
substantially affected by the gating
windows when evaluated with the
gamma statistics, suggesting the
interplay effect has a small role in
respiratory-gated RapidArc therapy.
Varied results were seen when gated
therapy was performed on the patient
plans that could only be attributed to
differences in patient respiratory
patterns. Patients whose plans had the
largest percentage of pixels failing the
gamma statistics exhibited irregular
breathing patterns including substantial
inter patient variation in depth of
respiration.
Regular sinusoidal wave forms using
phantom results were within acceptable
limits. Gamma evaluation using Imatrix
with 3% & 3mm criteria passed >97pixel
and the absolute dosimetry were within
±2% for all the patients. These results
were encouraging and gave us
confidence that our planned and
delivered fluencies were within the
acceptable clinical limit.
risk of its spread. The IEDCR (Institute
of Epidemiology, Disease Control and
Research) has identified Zika from
previous stored samples and has
developed national strategy for Zika
viral disease identification. Training has
also been given for health care person-
nel along with finalization of case
definition of Zika related micro-
cephaly. Along with this on-going
training progress in Zika identifica-
tion among health workers, aware-
ness should be increased among
common people as well. For
preventing Zika related micro-
cephaly and other malformations
of newborn we also have to
ensure and strengthen regular
antenatal care, examine all infants with
microcephaly for proper evaluation of
the cause and to enroll birth defect
cases in the national birth defect
surveillance system to observe the
trend of these birth defects, identify and
notify these to avoid disease outbreak.
4 >>>
 Issue-19 | Quarter-3, 2017

Prevalence of RH-HDN (Haemolytic Disease of Newborn)

Dr Md Redwanul Huq Masum, Prof Brig Gen (Retd) Zahid Mahmud

Haemolytic disease of newborn (HDN) results from
feto-maternal blood group incompatibility, most often in ABO
and Rh blood group and rarely in other minor blood group
systems. The pregnant mother develops an antibody against
fetal red cell antigens that crosses the placenta and causes
destruction of fetal red cells. HDN due to ABO incompatibility
are common, mild and passes on unnoticed in majority of the
cases. HDN due to Rh incompatibility, mainly Rh D, are often
severe and causes clinical problems.
Rh-HDN has the following characteristics:
a. In the majority of the cases, the mother is of blood group ‘O’
Rh D -ve and the fetus is of blood group A, B or AB Rh D
+ve.
b. It does not usually occur in first pregnancy. The chance of
fetal HDN increases with successive pregnancies
Prevalence of Rh HDN in United Hospital in the last 05 years
(April, 2012 – March, 2017) is shown in the following table
(Table 1):
Total no of Rh Detection of Rh Severity
antibody tests done in Rh antibody antibody of
UHL lab in last 5 years No. (%) titer HDN
1:4 Mild
217 3 (1.38) 1:8 Mild
1:64 Severe
While worldwide data are not available, the percentage of
presence of Rh antibody in D-negative women alloimmunised
following a D-positive pregnancy in USA in 1960s & 1970s (1)
is shown in the following table (Table 2):
Year Presence of Rh antibody (%)
1960 s 14
1970 s 1-2
It is obvious from the above mentioned data that the prevalence
of the presence of Rh antibody in D-negative women
alloimmunised following a D-positive pregnancy resulting in
HDN in subsequent pregnancies has decreased greatly in last
few decades.
Possible reasons for decreased prevalence of HDN are:
• Introduction of routine antenatal anti-D prophylaxis
(RAADP):
For Rh negative mothers who have not developed antibodies
yet, there are currently two ways of receiving RAADP-
1) a one-dose treatment: where pregnant women receive an
injection of immunoglobulin at some point during 28 to 30
weeks of their pregnancy
2) A two-dose treatment: where pregnant women receive two
injections; one during the 28th week and the other during the
34th week of pregnancy.
• Injection of Anti-D immunoglobulin within 72 hours of child
birth, if the mother is RhD negative and the baby is RhD
positive, and the mother hasn’t already been sensitized
• Decreased number of children reduces the prevalence of
HDN, as the risk of HDN increases with subsequent
pregnancies
• Increased awareness, e.g. preferring caesarean section
than normal vaginal delivery result in decreased chance of
transmission of fetal red blood cells into mother’s circulation
Antenatal checkup for Rh negative mothers having anti-D
antibodies (Rh alloimmunized women):
- Anti-D antibody titers are typically performed monthly until
24 weeks of gestation, after which period titers should be
repeated every 2 weeks.
- Pregnancies in which antibody titers are 1:8 or lower can be
managed by serial monitoring of maternal antibody titers.
- If the titer is 1:16 or higher, fetal wellness assessment is
compulsory by ultrasonography to evaluate middle cerebral
artery peak systolic velocity (MCA-PSV) or serial
amniocentesis for delta OD450 (a bilirubin derivative) if the
former is not available.
- Spectrophotometric analysis of amniotic fluid bilirubin
derivative can be performed to detect the presence of fetal
HDN and its severity. The amount of delta OD450 in
amniotic fluid samples can be used to estimate the degree
of fetal haemolysis.
- When fetal haematocrit is less than 30%, detected in fetal
blood sampling, the only therapeutic option is intrauterine
fetal transfusion.

World Breast Feeding Week 2017

On 1 August 2017, the inaugural
ceremony of World Breast Feeding
(WBF) week 2017 was held at Osmani
Milonayoton organized by BFF,
HPNSDP, WHO, WABA & other NGOs
with the theme Sustaining Breast
Feeding Together. Health Minister Mr
Md Nasim was the chief guest of the
inauguration program where Dr Runa
Laila, Neonatology Specialist, Dr
Halima Akhtar, Obs & Gynae Specialist
and Nurses Ms Lovely Thigidi & Ms
Subasiny Mardy from United Hospital
attended. Breast feeding
promotes the wellbeing of
infant, mother & the entire
country. Since 1992, World
Breast Feeding week has been
observed in Bangladesh every
first week of August. To
achieve the WBF week theme,
it is essential to work together
to support breast feeding
programs & policies so that
future generations grow into
healthy strong citizens.

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Purchase & Procurement Department of United Hospital
United Hospital’s Purchase Department
is responsible for the management of
the hospital’s procurement process
which includes acquisition, distribution,
control & disposal of goods and
thereafter providing relevant services
and equipment necessary to support
the activities of the hospital.
Acting as the agent of the hospital in all
matters pertaining to purchase and
procurement, the department requires
special knowledge along with high
degree of integrity to obtain
“The right product”
“In the right quantity”
“At the right price”
“At the right time”
Purchase department needs to actively
and continuously participate is search-
ing ideas from manufacturers and circu-
lating suggestions among supply
sources in the pursuit of achieving cost
savings, product improvement and/or
process improvement.
The Purchase & Procurement Depart-
ment of United Hospital negotiates
contracts for medical supplies, food,
clothing and linen, office supplies and
transport equipment such as ambu-
lances. It's a complex job that requires
constant supervision to ensure appropri-
ate goods are purchased and adequate
inventory levels are maintained.
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The basic purchase objective is to
ensure the most optimum goods,
supplies, capital items and services are
procured at the lowest possible price.
The practice of competitive bidding
whether formal sealed bids (proposals)
or informal (quotations), not only
ensures reasonable price but also
guards against favoritism and fraudu-
lence. All purchases are made by the
respective purchase wings or through
emergency purchase orders, issued in
advance to concerned departments
who justify a need to the Head of
Purchase department. An approved
purchase order is required prior to the
purchase of any goods, capital items,
services, supplies and construction
items.
To avoid fraudulence, wastage and
misuse, all concerned staff and procure-
ment officials scrupulously and sponta-
neously follow, enforce and ensure full
compliance with the ethics
& regulations of United
Hospital. It is the policy of
United Hospital that all
properly approved and
competitively priced
purchase requisitions are
processed in a timely fash-
ion, resulting in accurate
payment through the
accounts payable depart-
ment.
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Issue-19 | Quarter-3, 2017
The Purchase Department is divided
into five units: General Purchase, Medi-
cal Purchase, Medicine Purchase, Food
& Beverage Purchase and Commercial
unit. The procurement methodology
used by the first four units is briefly
outlined below:
1. Requisition: Any user department of
the hospital can prepare a requisi-
tion for goods and services through
proper departmental approval
authority and send it to store, using
the Hospital Integrated System,
according to the type of goods. The
store will forward it to the purchase
department.
2. Sourcing: After receiving the
purchase requisition, the product is
identified as per user satisfaction
along with brand, origin and suitable
price. Then the purchase requisition
is approved.
6 >>>
 Issue-19 | Quarter-3, 2017

3. Vendor Selection:
For regular goods
all vendors are
pre-shortlisted by
the purchase
department. They
must be licensed
to the extent as
required by law. It
is the responsibil-
ity of this depart-
ment to verify
compliance and
the vendor is
considered pre-qualified provided no
adverse information is identified by
United Hospital.
4. Quotation/Price Offer: After requisi-
tion is approved, quotation/price
offer is collected from vendors
minimum of three wherever
possible. Quotations must be in
letterhead/ official pad and contain
detailed specification of product
mentioning the manufacturer’s
name, origin, pack size, price & price
validity etc. Contact person’s name
with phone number is also manda-
tory in quotation/price offer.
The purchase policies and proce-
dures of United Hospital promote
strong internal controls to ensure
that only those goods and services
approved for purchase are charged
accurately to specific accounts and
meet the requirements/ standards of
the user department.
5. Emergency Purchase: An emer-
gency purchase is defined as the
purchase of commodities or
services, regardless of amount,
where the purchase is made as a
result of a sudden and /or unfore-
seen demand. The requesting
department must notify the purchase
department of the nature of the need
for the emergency purchase.
The commercial unit deals with banking
& shipping aspects of items that are
imported directly by the hospital to meet
its diversified requirements. Commer-
cial personnel are familiar with CNF
Agents and have knowledge of all rules
and regulations of Customs and the
National Board of Revenue which
enable them to do their work smoothly.
Capital Equipment is defined as equip-
ment with an acquisition cost of BDT
10,000 (ten thousand) or more and a
useful life of at least one year. Both
requirements must be met in order for a
product to be considered as capital
equipment.
The Purchase department maintains
close working relationship with the
accounts department and provide all
assistance with regard to submission of
bills & documents and any other
information/ work that may be required
to complete the post-purchase steps.
Where appropriate, issuance of
business to competing vendors via
separate purchase order is done. The
competitive process allows for multiple
contract awards provided all vendors
agree to adhere to the hospital
purchase policy and meet the specific
requirements of the user department. In
some cases, quotations are taken for a
fixed period and contract awards are
given for a fixed period with an option to
renew for a specified period depending
on market price fluctuation.
Occasionally, vendors offer to have their
equipment used on a trial basis in order
to determine its usefulness to a depart-
ment. When presented with this oppor-
tunity, the purchase department tries to
take advantage of such option. Once
the terms have been agreed upon, the
department uses the equipment for the
specified period of time. At the end of
the trial period, the equipment is
returned to the vendor at no cost to
United Hospital. During selection of
equipment the purchase department
reviews the reputation, reliability, capa-
bility, experience as well as expertise of
the vendor/ supplier; availability of
goods and services as per hospital
demand; availability of replacement
parts and technical assistance; warran-
ties offered by the supplier which may
include service and repair by the
supplier; delivery period and cost etc.
The department continuously tries to
ensure that the patients of the hospital
are provided
with the best
possible prod-
ucts in a safe
environment at a
c o s t - e ff e c t i v e
price.

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 Issue-19 | Quarter-3, 2017
Scar Endometriosis - A Dilemma
Dr Nighat Ara, Dr Naseem Mahmud, Dr Nusrat Zaman
A 35 years old female presented with a painful lump on lateral
aspect of a pfannenstiel incision 10 months after caesarean
section. Abdominal examination revealed a firm tender lump
with history of gradual increase in size of 3x3 cm with no
discharge. USG revealed a bright heteroechoic mass followed
by MRI revealed extension on external oblique aponeurosis
and also onto muscle wall. It showed endometrial glands and
stromal cells confirming two findings of the pathological triad of
endometriosis. FNAC was done. The scar initially was thought
to be a scar granuloma and treated conservatively. However, as
the lump persisted getting enlarged in size, surgical intervention
was done with wide excision of the lump under general anaes-
thesia.
In pathology, fibro adipose tissue with interspersed gland and
stroma reinforced the findings of FNAC thus confirming the
diagnosis of Endometriosis.
Scar Endometriosis (SE) i.e. Incision Endometriosis is a rare
condition; though growing prevalence of gynaecological and
obstetric surgeries has made it an issue to concern. In general,
estimated 89 millions women of reproductive age group have
been affected with this worldwide. The prevalence of surgical
Endometriosis is about 1.6%; yet posing significant clinical
importance specially with increasing hysterectomy and
caesarean section, contributing 1.08 - 2% and 0.03 - 0.4%
respectively.
Hypertrophied Scar Endometriotic Scar
The aetiology attribute to the direct implantation of decidual
cells during various gynaecological and obstetric surgeries,
which subsequently proliferate or induce metaplasia in the
surrounding cells under the influence of oestrogen.
Diagnosis of SE is always challenging as it may appear after an
interval of 3 months to 10 years of the primary surgery.
Commonest sites being abdominal skin and subcutaneous
tissues through rectus sheath is hardly involved. Symptoms
often mimic common surgical complications like appearance of
painful lump in or around the surgical scar, but in SE the lump
remains persistently enlarged in size or exhibits unsightly,
discolored hypertrophic scar which is severely tender on palpa-
tion. Cyclicity of symptoms during menstruation like classical
endometriosis is not always among the findings.
To establish SE presence of 2 out of 3 criteria of pathological
Triad (Endometrial gland, Stromal cells, haemosiderin laden
macrophages) need to be present along with the symptoms.
Workshop on Antimicrobial Consumption Monitoring
Md Anisur Rahman, In-charge United Hospital Pharmacy, attended a two day long workshop on 9 & 10 August 2017 on
Antimicrobial Consumption Monitoring, organized jointly by Directorate of Drug Administration & WHO, which was chaired
by Director General Maj Gen Mostafizur Rahman. With representatives of WHO & FAO, in total 60 doctors, pharmacists &
other healthcare professionals, participated here to study the WHO survey on current antimicrobial use trend and resistance
pattern with a view to develop a national program on antimicrobial usage & surveillance.
Exceptional People...
Exceptional Care Hotline 10666 | Emergency
Issue-19 | Quarter-3, 2017
Often the lesion appears to be a firm nodule; FNAC becomes
the first choice of diagnostic tool which gives a full histological
picture that helps differentiating it from metastatic disease like
desmoid tumor, lipoma, sarcoma, fasciitis, hematoma, abscess
and fat necrosis. Imaging modalities like USG, CT or MRI has
some use but not specific.
MRI is much preferred than CT due to its high special resolu-
tion, MRI detects planes between muscles and subcutaneous
tissues. It magnifies the extensions of affected tissues thus
helps planning operative resection especially recurrent and
large lesions.
The only treatment
modality is Wide
Surgical Excision of
the lesion of 1cm
range on all sides and
patch grafting of the
fascial defects.
It has been reported
that medical treat-
ment with OCP and
progestogen and Surgical Excision Removal of Endometriosis
gonadotrophin
agonist (Leuprolide acetate) has been in use but provides only
prompt improvement in symptoms which recur on withdrawal of
the treatment. Follow up, is of great importance as chances of
recurrence is high which requires re-excision. Malignant
change is very rare but continual recurrence imposes a threat,
so possibility needs to be ruled out.
Gold Standard Surgical Excision Removal of Endometriosis
Good technique and proper care during gynaecological and
obstetric surgeries help preventing Scar Endometriosis. Thor-
ough cleaning and vigorous irrigation with saline before closure
in extensive abdominal procedures is highly recommended.
Overall good surgical and gynaecological knowledge and
efficient examination helps better preventive and prognostic
care.
0191 400 1234 8 >>>

Anterior Cervical Decompression and Fusion without Fixation: A
Retrospective Study
Dr S S Ahmed, Dr Al Imran, Dr Sourav Chowdhury, Dr Saif Ul Haque
This specific study aimed to assess the
functional and radiological outcomes of
patients with Anterior Cervical Discec-
tomy and Fusion (ACDF) with cage
alone without screw and plate fixation for
cervical disc prolapse (degenerative or
traumatic, without instability) causing
cervical myelopathy and/or radiculopa-
thy at single or multiple levels (maximum
of four).
In this study patients with cervical
degenerative or traumatic disc disease
(without instability) from September
2007 to June 2016 were assessed retro-
spectively. A total of 66 patients were
treated in United Hospital by ACD and
Fusion with cage (Titanium/PEEK/ Com-
bined) at single or multiple level of cervi-
cal disc disease during this period. All
the patients who underwent ACD and
Impact of Renal Insufficiency on In-hospital Outcomes after Off-pump
Coronary Artery Bypass Surgery
Dr Sonjoy Biswas, Dr Syed Al-Nahian, Dr Saydur Rahman Khan, Dr Jahangir Kabir
Chronic kidney disease (CKD) is a
predictor of increased morbidity and
mortality in patients undergoing off-pump
coronary artery bypass surgery
(OPCAB). This retrospective study was
conducted to evaluate the characteristics
and predictors of increased morbidity
and mortality in the CKD population, who
have undergone OPCAB and to compare
in-hospital outcomes between patients
with and without CKD and with and
without development of acute kidney
injury (AKI).
A prospective analysis was done of all
isolated OPCAB performed at United
Hospital from January 2015 to October
2016. CKD was considered when e-GFR
was < 90 ml/min/1.73m2. Clinical charac-
teristics, mortality and post-operative
complications were evaluated according
to renal function and stages of CKD.
Exceptional People...
Exceptional Care Hotline
Fusion with cage alone were assessed
in consideration of radiological and
clinical outcomes. Robinson's criteria,
and posterior neck pain, arm pain
described by a 10 point visual analog
scale (VAS) and Neck Disability Index
(NDI). EQ-5D Questionnaire for overall
functional status was used to assess
clinical outcomes. Subsidence, rate of
fusion, Kyphotic angle and the degen-
erative changes in adjacent segments
were examined during follow-up exami-
nation.
VAS was
checked during
each follow-up
for all patients
and Robinson's
criteria, NDI and
EQ-5D Ques-
tionnaire were
used. Fusion
rates were
98.48% (65/66);
subsidence
rates were 6.06% (4/66), local and
regional Kyphotic angle difference
showed no significant disparity (pre and
post-operative). At the final follow-up,
Out of 1463 patients, 169 (11.6%) had
CKD, this population was older,
presented greater prevalence of
hypertension, left ventricular dysfunction,
prior stroke, peripheral vascular disease
and triple vessel disease, hence higher
Euro SCORE. In-hospital outcomes
revealed greater incidence of stroke
10666 | Emergency 0191 400 1234
Issue-19 | Quarter-3, 2017
adjacent level disease developed in
7.57% (5/66) cases.
In single or multiple levels ACD and
Fusion with cage alone would be a better
choice than additional screw and plate
fixation with regard to clinical and radio-
logical outcome. The same surgeon used
plate and screw routinely for single and
multiple levels previously and follow up
of those patients revealed significant
neck movement restriction and subse-
quent development of further disease at
levels above and below. However,
without plate and screw there is not
much complaint regarding movement,
and follow up revealed no further disc
prolapse at levels above and below, up to
five years since operation.
In conclusion, single or multiple level
ACD and Fusion with cage alone does
not require fixation by plate and screw
and definitely improves the functional
quality of life of the patient and prevent
subsequent complications associated
with plate and screw fixation. We suggest
that only fusion without fixation will yield
better postoperative functional outcomes
compared to those undergoing fusion
with fixation.
(4.4% vs 1.6%), atrial fibrillation (12% vs
6%), low cardiac output syndrome (12%
vs 7.2%), longer stay in intensive care
unit (4.84 vs 2.83 days) and greater
mortality (8.4% vs 2.4%). Female
gender, smoking, diabetes and
peripheral vascular disease were
associated with higher in-hospital
post-operative complications and
mortality within the CKD group. Patients
who did not develop post-operative AKI
presented 2.4% mortality; non-dialytic
AKI and dialytic AKI presented 16.7%
and 33.3% mortality respectively.
Mortality was directly related to the
stages of CKD.
In conclusion it can be said that, CKD
patients submitted to OPCAB represent
a high risk population, with increased
incidence of complications and mortality;
further post-operative AKI is a strong
in-hospital mortality predictor.
9 >>>
 Issue-19 | Quarter-3, 2017

Corporate Agreement Signing Health Awareness Talk as CSR Activity

and Facility Tour
United Hospital Limited signed Corporate Medical
Services Agreement with the following companies in
this quarter:

Awareness session on Let’s Talk About Healthy Diet was

organized on 16 July 2017 at Unilever (BD) Limited Corporate
Office, conducted by Ms Chowdhury Tasneem Hasin, In-Charge,
Dietetics & Nutrition Department.
Four awareness sessions on Chikungunya & Its Management
• Chartered Life Insurance Company Limited were organized on 24 & 26 July and 10 & 14 August 2017 at the
• Embassy of China in Bangladesh corporate offices of Aukotex Group, Nitol Niloy Group, Factory of
• Asian Paints (BD) Limited Aukotex Group and SGS (BD) Limited respectively. First three
• World Vision Bangladesh sessions were conducted by Dr Shamshad Khan, Specialist,
• Healix International, UK Internal Medicine Department and the last one by Dr Zeenat
Sultana, Junior Consultant, Internal Medicine Department.
The officials from following companies / organisations
visited United Hospital in this quarter.
• British High Commission, Dhaka on 07 August 2017
• British High Commission, Dhaka & Healix
International, UK on 13 August 2017
• International SOS, Singapore on 19 September 2017
• US Embassy, Dhaka on 26 September 2017

Hepatitis Awareness Campaign at East West

University
Risk and spread of different types of Hepatitis being prevalent among University
students, a daylong awareness campaign was conducted by United Hospital at
East West University campus on 20 September 2017 where basic health
checkup booth was set-up in
their Academic Bhaban, letting their students and faculties avail complimentary
health checkup & doctor consultation; this was coupled with an awareness talk
delivery on Hepatitis risks & prevention at their Central Auditorium by Dr Shamshad
Khan, Specialist of Internal Medicine Department. Enthusiastic students, faculties
& other University staff, who thronged in the booth browsing through the flyers,
brochures and festoons of United Hospital demonstrated their interactive
spontaneity in this Hepatitis awareness drive.

Scientific Seminars
Date & Venue Programme Title Speakers Remarks
27 July ’17 Chronic Viral Dr Mohammed Mahbub Alam, In
Hepatitis & Its Consultant, Gastroenterology & Hepatology commemoration
United Hospital
Seminar Hall
Management Dr Fowaz Hussain of World Hepatitis
Consultant, Gastroenterology & Hepatology Day
21 August ’17 Capsule Endoscopy Dr Dhakshitha Wickramasinghe To mark launching
United Hospital University of Colombo of Pillicam Capsule
Seminar Hall Endoscopy

22 August ’17 Recent Advances in Dr Md Rashid Un Nabi Jointly organized

Conference Room Clinical Practice of Consultant, Radiation Oncology with Teacher’s
Khulna Medical Oncology and Dr Tanveer Bin Latif Association, Khulna
College Nephrology Consultant, Nephrology Medical College

Exceptional People...
Exceptional Care Hotline 10666 | Emergency 0191 400 1234 10 >>>
 Issue-19 | Quarter-3, 2017

Participation in International Conferences

Nephrology Chief Consultant Prof Mujibul
Haque Mollah attended the 11th
International Congress of International
Society for Hemodialysis (ISHD) in
Thailand from 2 to 5 August 2017 along
with 2000 participants from all over the
world.
Dr Kaisar Nasrullah Khan, Consultant
Along with 25000 other participants Dr Cardiology attended a Weekly
Ferdous Shahriar Sayed, Medical Fellowship Course on Rovus (ROTA,
Oncology Consultant attended the Annual IVUS & FFR) from 31 July to 4 August
Conference of ESMO (European Society 2017 at Tokyo University, Tokyo,
of Medical Oncology) held at Madrid, Japan. A total of 8 participants
Spain from 7 to 11 September 2017; this attended the course including 5 from
is the second largest conference after the Bangladesh.
annual ASCO (American Society of Clinical Oncology) meeting in USA.

Endocrinology Consultant Dr Nazmul Islam

attended the 53rd annual meeting of European
Society for Advancement of Diabetes in Lisbon,
Portugal from 11 to 15 September 2017, along
with 10000 diabetes experts from all over the
world.

On 7 & 8 July 2017, Dr Sharif Ahmed, Cardiology Specialists Dr Tunaggina

Specialist & Coordinator of Cancer Care Afrin Khan and Dr Samsun Nahar
Center did a poster presentation on attended Malaysia Live annual
observational study titled Rivaroxaban conference on interventional cardiology
Compared To Low Molecular Heparin from 27-29 August 2017 in Hotel Hilton,
For Preventing Weight Malignancy Kualalampur. They exchanged views in
Associated Venous Thromboembolic the session and explored different
Event & Its Compliance in a conference at Best of ASCO (American Society of aspects of difficult and complicated
Clinical Oncology) Asia 2017 in Singapore. cases of interventional cardiology.

Training & Workshop

Along with 28 doctors from different

Indian Association for Parenteral &
Enteral Nutrition (IAPEN) organised a
workshop on Critical Care Nutrition on
11 September 2017 where ICU
Intensivist Dr Mir Atiqur Rahman,
In-Charge Dietetics and Nutrition
Department Ms Chowdhury Tasneem
Hasin and Dietitian Ms Fatima Gazi
from United Hospital participated.
hospitals, United Hospital Oncology
Specialist Dr Sharif Ahmed attended
National Training Program on Contouring
of GI and CNS Cancer arranged by IAEA
(International Atomic Energy Agency),
BAEC (Bangladesh Atomic Energy
Commission) & Oncology Club from 10
to 14 September 2017 at INMAS
Auditorium, Dhaka Medical College.
United Hospital Neonatology Specialist
Dr Sharmin Afroze and Senior House
Officer Dr Md Toyobur Rahaman
presented United Hospital newborn care
service practices in the 2 day progress
review meeting of NBBD (Newborn Birth
Defect) held in Bangabandhu Sheikh
Mujib Medical University Dhaka on 23 to
24 July 2017.

Along with 27 participants from all around the country Sharifun Nahar,
Radiotherapy Technologist of United Hospital attended a 5 day training program on
Radiation Protection for Radiation Workers and RCOs of BAEC Medical Facilities
and Industries, held from 20 to 24 August 2017, arranged by Bangladesh Atomic
Energy Commission (BAEC).

Exceptional People...
Exceptional Care Hotline 10666 | Emergency 0191 400 1234 11 >>>

New Consultants
Dr. Raqibul M. Anwar
MBBS, LRCP, (Edin), LRCS (Edin), LRCPS (Glasg)
MA, MSc, FRCS (Glasg), FRCS (England)
FRCS (Intercollegiate Gen Surgery)
Department of General, Laparoscopic and
Colorectal Surgery
Prof. Dr. Touhida Ahsan
MBBS, FCPS (Obs & Gynae), MS (Obs & Gynae)
Department of Obs & Gynae
World Heart Day Observance
World Heart Day takes place on 29 September each year.
This year theme of World Heart Day was Share the Power.
United Hospital commemorated the event like every year
with a range of activities. Health Checkup Booth at lobby
was inaugurated by CEO Mr Najmul Hasan and Cardiac
Centre Consultants, where regular health check,
complimentary doctor consultancy and diet counseling by
the dieticians were given, Awareness sessions on Heart
Health were conducted in different corporate companies
along with offering special Cardiac Packages for the patients
and their attendants.
World Physiotherapy Day Observance
World Physiotherapy Day is observed globally on 8 September;
the day being Friday this year, it was celebrated in United
Hospital on 9 September 2017 in a befitting manner upholding
the theme Physical Activity For Life. The programme was
festive with cake cutting and gracious presence of Consultant
and senior management of the hospital. Physical Medicine &
Rehabilitation Consultant Dr Lt Colonel S M Shahidul Haque,
and Neurosurgery Consultant Dr Syed Sayed Ahmed,
emphasized on the essential role of physiotherapy in enhancing
the services provided to the patients.
Chief Adviser Editor-In-Chief Editorial Board
• Najmul Hasan • Dr Shagufa Anwar • Dr Mahboob Rahman Khan
• Hanufa Ahmed
Issue-19 | Quarter-3, 2017
Congratulations to the Newly Weds on
their Marriage
• Senior Staff Nurse Mst Kakoli Khatun of
Emergency Department got married to
Md Shahriar Hasan on 1 July 2017
• Senior Staff Nurse Gitashri Mondol of 3rd Floor Oncology
Ward got married to Shamanuj Roy on 3 July 2017
• Physiotherapist Horain Akter (Disha) got married to Syed
Nadeem Ahsan on 7 July 2017
• Appointment Call Center Officer Md Mainul Islam got
married to Mourin Farahit on 28 July 2017
• Customer Relation Officer Mahfujur Rahman Chowdhury
got married to Mariam Akhter on 2 August 2017
• Housekeeping Attendant Md Salauddin got married to
Jannatul Maowa on 4 September 2017
• Customer Relation Officer Md Shafiul Azam Hiru got
married to Jannat Ara Shifa on 5 September 2017
• Customer Relation Officer Kazi Azharul Islam got married
to Marjana Jannat Mira on 26 September 2017
Congratulations & Best Wishes to the
following Staff and their Spouses
• Junior Nurse Nirupoma Rozario of
Haemodialysis Unit was blessed with a
daughter Namrota Rozario on 5 April
2017
• Senior Staff Nurse Sharmin Akter of 5th
W/A,1st Desk was blessed with a son
Shamiul Hasan Alif on 26 April 2017
• Dr Jan Mohammad, Consultant Radiology & Imaging was
blessed with a daughter Areeba Waniya on 2 July 2017
• Duty Manager Sabbir Ahmed of Admin Department was
blessed with a daughter Junaira Jannat on 5 July 2017
• Nursing Unit Supervisor Smriti Mondol of GHDU was
blessed with a son Rehan on 17 July 2017
• Support Staff Md Abbas Ali of Admin Department was
blessed with a son Sadman Ahmad on 13 August 2017
• Senior Staff Nurse Anju Mondol of Pre-Cath Ward was
blessed with a daughter Tonoya Mondol on 17 August 2017
• Senior Staff Nurse Karuna Rangsa of Neuro Ward was
blessed with a daughter Sangita Rangsa 18 August 2017
• Senior Staff Nurse Mst Fatema Khatun of Pre-Cath Ward was
blessed with a daughter Faria Islam Rifa on 19 August 2017
• Duty Manager Matiar Rahman of Admin Department was
blessed with a daughter Marium Rahman on 27 August 2017
• Blood Bank Specialist Dr Md Mizanur Rahman Chowdhury
was blessed with a son Nuraz on 14 September 2017
Condolence & Prayers
• Coordinator, Clinical Support Dr Khandaker Abdul Asad
passed away on 12 July 2017
• Medical Oncology Consultant Dr Ashim Kumar Sengupta
lost his daughter Adrija Sengupta on 26 July 2017
Communication Support Graphic Design Printed By
• Syed Ashraf-ul-Masum • Jamayet Hossain Russell • Creation
• Luna Nasreen Tarafdar